ALCOHOLIC BEVERAGE APPLICATION

ATTENTION BUSINESS OWNERS

Owners with 10% ownership or more must attach the following documents with the

Alcoholic Beverage Application:

1. Completed GCIC (Georgia CrimeInformation Center) form

2. Copy of owner’s driver’slicense.

Failure to provide both documents will delay processing of the alcohol

application.

3120 Stonecrest Blvd, Stonecrest, GA 30038 www.stonecrestga.gov

ALCOHOLIC BEVERAGE CHECKLIST

DATE:

Contact Name:

Contact Telephone #:

Business Name: (Corp.):

(d/b/a):

Business Address: Should you have any questions, please contact The City of Stonecrest – City Hall at 770-224-0200

CHECK OFF LIST FOR ALCOHOLIC BEVERAGE LICENSE

Note: The items checked below must be submitted with your application or prior to issuance of your license.

( ) APPLICATION - In Duplicate - Must be fully completed, application must be signed & notarized. Two copies of your corporate papers must be filed with your application if the business is incorporated. Also, the applicant must provide a listing of the corporate officers.

( ) PERSONNEL STATEMENTS - In Duplicate - Required on licensee, sole proprietor, all partners, any person with 10% or more stock ownership of the corporation, and all corporate officers. Two (2) original pictures and two (2) copies of each person’s driver’s license are required. If nodriver’s license, please attach two (2) copies of your military or state issued identification card.U S Citizens must provide two legible/readable copies of their birth certificate or naturalizationcertificate. Resident Aliens must provide two legible/readable copies of their ImmigrationCard. Poor quality copies are not acceptable.

( ) REGISTERED AGENT - In Duplicate - All businesses with a license to sell beer, wine or liquor must have and continuously maintain a registered agent who lives in DeKalb County. The owner can be the registered agent if they live in DeKalb County, but they must complete the registered agent forms. Two pictures and two copies of the agent’s driver’s license are required.

( ) AFFIDAVIT - In Duplicate - For Liquor Sales - Person having knowledge of applicant’s residence.

( ) LEGAL LAND SURVEY - All new locations and closed stores/businesses must provide a new survey which was measured no more than 30 days prior to filing date of the alcohol license application.

( ) FLOOR PLAN DRAWING - In Duplicate – All applicants must provide a drawing of their business that shows a detailed layout of the inside of the business and the drawing shall show all entrances and exits. Nightclub and restaurants must show their bathrooms, kitchen, office and customer areas.

( ) COPY OF MENU - In duplicate - Nightclubs and Restaurants - Food and beverage service.

( ) LICENSE FEES - CASHIERS CHECK or MONEY ORDER ONLY - Make payable to CITY OF STONECREST. The license fees must be paid when the application is filed for processing. The prorated fees include the month of application, plus the remaining months in the calendar year and any portion of a month is counted as a full month. Do not forget to include the administrative fee(s).

( ) BUSINESS LICENSE REGISTRATION - Zoning Department must approve all business locations.

( ) BACKGROUND INVESTIGATION & CONSENT FORM - A background investigation consent form (in duplicate) and fee of $50.00 per person applies to the registered agent and everyone who must complete personnel statements. The duplicate copies requested above will be sent to the Public Safety by our office. They will advise our office in writing when the investigation is completed. This fee must be paid with a separate Cashier’s Check or Money Order, payable to: DeKalb County Police Dept.

( ) CERTIFICATE of OCCUPANCY - Zoning Department will make decision. Telephone (770) 224-0200 City of Stonecrest. The zoning dept. usually requires a new building permit application, entertainment letter, copy of Fire Dept. approval, copy of food service permit and a minimum filing fee of $75.00 for businesses with a consumption on premise alcohol license (nightclubs, restaurants and sports bars). Forms can be obtained from zoning.

( ) FIRE DEPARTMENT APPROVAL - Restaurants and nightclubs - Call (404) 371-2611 for inspection.

( ) HEALTH DEPARTMENT - Restaurants and nightclubs are required to get a new food service permit. Call (404) 508-7900 or visit their office at 445 Winn Way, Decatur, Georgia 30033.

( ) SANITATION SERVICE - Applicants must provide proof of sanitation service or establish service before a license can be issued. Call (404) 294-2900 to set up service.

*- ( ) REVIEW – Additional Information on the Reverse Side and the City Alcohol Ordinance.

CITY OF STONECREST, GEORGIA

( ) LIQUOR STORES – Retail package sales of distilled spirits. Georgia Law, Article 2 of Chapter 4, Section 3-4-27 requires the applicant to provide proof of a legal advertisement in the Champion News, located at 217 East Trinity Place, Decatur, Ga. 30030. Telephone number - (404) 373- 7779.

( )LEGAL LAND SURVEY: For all new locations and closed stores/businesses must provide a new survey which was measured no more than 30 days prior to filing date of the alcohol license application.

1. It is advisable that applicants for any business, liquor, beer and/or wine licenses do not sign anycontracts, make expenditures, or commit themselves in any manner without first makingthemselves aware of all requirements for State and County Code compliance.

2. All new locations must submit a land survey with their application for a beer, wine or liquorlicense. A new survey will not be required on changes of ownership if the purchaser is applying forthe same type of license, provided the business is still open and operating. Locations previouslylicensed are not grand-fathered if the business closes. 3. The applicant is responsible for schedulingtheir inspections by the fire and health departments, and the zoning department must approve allbusiness locations before a business or alcohol license can be issued. The applicant is responsiblefor delivery of the final inspections to our office.

4. Any questions you may have with regard to the interpretation of the DeKalb County Code or howit applies to your particular situation must be submitted in writing to the alcohol licensingmanager. Your questions will be reviewed and answered in writing as appropriate.

5. STATE LICENSE - In addition to the County License, a State License is required. The County License is notvalid without a current State License. Please contact the State of Georgia Revenue Department at (404) 417-4490 to obtain forms and information to file for a State License. Their office is located at:1800 Century Center Blvd, 2nd Floor, Atlanta, Georgia 30345.

6. FEDERAL PERMIT - Federal Law requires a Federal Occupational Tax Stamp for alcohol sales. Pleasecall1- (800) 398-2282 for additional information. They will mail application forms to you.

7. CITY LICENSE FEES ANNUAL FEE (Jan 1 through Dec 31)Liquor $4,000.00 Consumption or package sales ( Mon thru Sat) Beer only $600.00 Consumption or package sales ( Mon thru Sat) Wine only $600.00 Consumption or package sales ( Mon thru Sat) Beer & Wine Combination $900.00 Consumption or package sales ( Mon thru Sat) Additional Fixed Bar $600.00 Consumption on premises only ( Mon thru Sat) Additional Movable Bar $300.00 Consumption on premises only ( Mon thru Sat) Sunday Sales Permit $1,100.00 Consumption on premises only ( Only one fee) 8. The following fees are not prorated:Charitable Nonprofit = $50.00 per day for beer and/or wine. $50.00 per day for liquor.Fraternal Organizations = $500.00 annual for beer and/or wine. $1,000.00 annual for liquor.Wholesalers = $600.00 each for beer or wine, plus $4,000.00 for liquor.Administrative/application fee = $100.00 for beer and/or wine, Plus $200.00 for liquor.

9. Mixed drink tax returns – Consumption on premises businesses that sell distilled spirits arerequired to report and pay excise taxes of three (3) percent each month on the liquor sales only.These taxes must be paid promptly each month to avoid suspension or revocation of your license.

10. An alcohol license allows alcohol sales Monday through Saturday. Eating establishmentsmeeting the minimum food sales requirement may purchase a Sunday Sales permit. TheSunday Sales permit will allow alcohol sales on Sunday from 12:30 noon until 02:55 a.m.Monday morning.

11. Employee permits to work in liquor stores or at consumption on premises establishments must beobtained from the DeKalb County Public Safety Department. Please call them at (404) 297- 3934.The alcohol license must be issued to the business before any employee permits will be issued

ALCOHOLIC BEVERAGE LICENSE APPLICATION

City of Stonecrest 3120 Stonecrest Blvd Stonecrest, GA 30038 Phone: (770) 224-0200

INSTRUCTIONS: PLEASE PRINT OR TYPE APPLICATION AND ANSWER ALL QUESTIONS. Please fill out entire application. If a portion does not apply to you mark it N/A. Do not leave anything blank.

TYPE OF LICENSE: (Check appropriate spaces)

NEW CHANGE OF OWNERSHIP

( ) ( )

( ) RETAIL/PACKAGE ( ) CONSUMPTION ON THE PREMISES ( ) MANUFACTURER

( ) Wine & Beer ( ) Wine ( ) Beer Beverage

( ) WINE TASTING ( ) Distilled Spirits (Liquor) ( ) BEER TASTING ( ) Growler Beer Beverage ( ) CATERING (EVENTS) )

a. Restaurant ( ) b. Bar or Lounge ( ) c. Package Store ( ) d. Private ( ) e. Food Store ( ) f. Service Station ( ) g. Hotel/Motel ( ) h. Sunday Sales ( ) i. Additional Bar(s) ( )

1. Full Name of Business

Under what name is the Business to be operated

Is the business a proprietorship, partnership, corporation, domestic or foreign?

2. Business Address

3. Phone Beginning Date of Business in City of Stonecrest

4. [ ] New business [ ] Existing business purchase

If change of ownership, effective date of this change

If change of ownership, enclose a copy of the sales contract and closing statement.

5. Federal Tax ID Number Georgia Sales Tax Number

6. Does the business meet the distance requirements from the following?

CHURCH, SCHOOL GROUNDS, COLLEGE CAMPUS YES NO

Wine, Beer Beverage, Distilled Spirits 200 Yards (Church) 200 Yards (School) ( ) ( )

7. Full name of Applicant

Business

Number:

Alcohol Beverage

License Number:

Business Occ Tax

Number

(GA) Alcoholic

Beverage License

Number

Full name of Spouse, if married

Are you a Citizen of the United States or Alien Birthplace?

Current Address City St Zip

Home Telephone

Number of years at present address

Do you reside in DeKalb County If yes, how long

Previous address

Number of years at previous address

State Driver's License Number

What has been your occupation for the past five (5) years? Give detailed list.

8. Applicant's employment date with present business

If new business, date business will begin in Stonecrest

If transfer or change of ownership, effective date of this change

If transfer or change of ownership, enclose a copy of the sales contract, closing statement

Previous Applicant

D/B/A

9. What is the name of the person who, if the license is granted will be the active manager of thebusiness and on the job at the business? List address, occupation, phone number, and employer.

10. Has the applicant, spouse, or any individual having an interest either as owner, partner, or stockholder,been arrested, convicted or entered a plea of nolo contendere within ten (10) years immediately prior tothe filing of this application for any felony or misdemeanor of any state or of the United States, or anymunicipal ordinance except traffic violations?If yes, describe in detail and give dates.

11. Do you own the land and building on which this business is to be operated?If not, please list the manner in which the rent is determined.

Attach a copy of the lease and any other pertinent documents.

12. How is the proposed location zoned?

13. If operating as a corporation, state name and address of corporation, when and where incorporated, andthe names of the officers and directors and the office held by each.

14. If operating as a corporation or partnership, list the stockholders (10% or more) and the amount of interestof each stockholder in the corporation or partnership.

15. If an individual, state names of any other persons or firms owning any interest or receiving any funds fromthe corporation.

16. If this is an application for any retail license hereunder, has applicant or spouse received any financial aidor assistance from any manufacturer or wholesaler of alcoholic beverages?

17. If this is an application for any retail license hereunder, has applicant or spouse any financial interest inany manufacturer or wholesaler of alcoholic beverages?

18. State whether or not applicant, partner, corporation officer, or has been denied for an alcohol beveragelicense in the county of DeKalb in the preceding 2 years. (Submit full details)

19. Do you or your spouse or any of the other owners, partners, or stockholders have an interest in otherliquor stores? If so, state in how many stores?

20. All beer, wine and liquor retailers shall only purchase alcoholic beverages from a State of GeorgiaLicensed Wholesaler as per Georgia Alcoholic Beverage Laws and Regulations, 1996 Edition, as now orhereafter amended, Chapter 560-2-2.04. Initial

21. Do you have any questions or comments regarding the ordinances, laws, regulations or application?

( ) Yes ( ) No

22. Are you familiar with the City of Stonecrest ordinances, state laws and, regulations, federal laws andregulations governing the operation of this type of business? ( ) Yes ( ) No

23. Have you made application for a State license? ( ) Yes ( ) No

24. Have you answered all questions? ( ) Yes ( ) No

Subscribed and sworn to before me

This day of , 20 .

(Clerk/Notary Public) (Signature of Named Individual)

My commission expires:

DEKALB COUNTY REGISTERED AGENT FORM City of Stonecrest Alcohol License, 3120 Stonecrest Blvd, Stonecrest GA 30038

Business Name: _ Business Address: City/State/Zip Code:

DeKalb County Code Section 4•27 requires every business applying for or holding an alcoholic beverage license to have and continuously maintain a registered agent for service of process of any notice permitte d by law under the alcoholic beverage ordinance. The registered agent must live in DeKalb County. The owner can be their own registered agent if they live in DeKalb County. I,

, do hereby consent to serve as the registered agent for the licensee, owners, officers an d/or directors of the above business and to perform all obligations of such agency under the provisions of DeKalb County Code Section 4•27. I also consent to the required criminal background investigation in order to serve as a registered agent.

Agent’s Name (type or print clearly) Agent’s Social Security Number

Agent’s Home Address Agent’s Birthday (Month, day & year)

City, State & Zip Code Sex Race Height Weight

Signature of Agent Date Agent’s Home Telephone No.

Agent’s Business Telephone No.

The owner(s) or an officer of the corporation must authorize the person shown above to be their agent. It is the owner’s responsibility to maintain a registered agent who lives in DeKalb County. Please attach a money order, payable to DeKalb County Public Safety, for $50.00 to this form to cover the background in vestigation. Failure to maintain a registered agent shall be grounds for suspension or revocation of your a lcoholic beverage license.

Licensee’s Name (Type or print clearly)

Licensee’s Signature Date

Owner’s Name (Type or Print clearly)

Owner’s Signature Date

Officer’s Name (Type or print) Title

Officer’s Signature

TYPE OF LICENSE: LICENSE FEE:

CONSUMPTION ON THE PREMISES: Wine $ 600.00 Beer Beverages $ 600.00 Wine and Beer Beverages $ 900.00 Distilled Spirit (Liquor) $4,000.00 Wine, Beer Beverages & Distilled Spirits $4900.00 Additional Bar Fixed @ $600.00 (Each) Additional Bar Movable @ $300.00 (Each) Sunday Sales (Only one fee) $1,100.00 Sunday Sales Malt Beverage $250.00 Sunday Sales Wine $250.00

HOURS OF OPERATION PACKAGE - BEER AND WINE

PACKAGE - BEER AND WINE

Monday through Saturday

Election Day- Licensees may open their establishments for the sale of alcoholic beverages on any election day

(City, State, Federal, or County) *Not allowed within 200 feet ofPolling Place, during polling hours*

PACKAGE - LIQUOR Monday through Saturday Sunday No Sunday Sales Election Day . (City, State, Federal, or County) *Not allowed within 200 feet of

Polling Place, during polling hours*CONSUMPTION ON THE PREMISES – BEER, WINE AND LIQUOR 1Eating Establishment ONLY – establishment which is licensed to sell alcoholic beverages and which derives at least 50 percent (50%) of its total annual gross food and beverage sales from the sale of prepared meals or food. [Article 2, Section 5(a)] and [Article 3, Section 3(c)]

Sunday 12:30 PM – 2:55 AM Election Day- Licensees may open their establishments for the sale of alcoholic beverages on any election day

Monday 9:00 AM – 3:55 AM (City, State, Federal, or County) Tuesday 9:00 AM – 3:55 AM *Not allowed within 200 feet ofWednesday 9:00 AM – 3:55 AM Polling Place, during polling hours*Thursday 9:00 AM – 3:55 AM Friday 9:00 AM – 3:55 AM Saturday 9:00 AM – 2:55 AM

NO SALES Sunday ALL DAY Monday - Saturday 3:00 AM – 9:00 AM

City of Stonecrest 3120 Stonecrest Blvd

Stonecrest, Georgia 30038 Phone: (770) 244-0200

FOOD SALES AND ALCOHOLIC BEVERAGE SALES AFFIDAVIT **DOES NOT APPLY TO RETAIL PACKAGE**

NAME OF ESTABLISHMENT:

ADDRESS OF ESTABLISHMENT:

LICENSEE’S NAME BUSINESS LICENSE #:

I. FOOD SALES AND ALCOHOLIC BEVERAGE SALES. Final reports must be attached to support the reported salestotals or CPA certification must be completed attesting to the reported sales totals. This information must be providedfrom the financial records of the above establishment on a calendar-year basis, or such period during which theestablishment has been open.

PERIOD FOR WHICH INFORMATION IS PROVIDED: (If existing business, must be 12-month period. If new business must be 12-month estimate)

Gross Receipts from Food Sales this period: $ ( %)

Gross Receipts from Alcoholic Beverage Sales this period: $ ( %)

Total Food Sales and Alcoholic Beverage Sales this period: $ ( %)

Briefly describe the method by which receipts are segregated daily into food sales and alcoholic beverage sales:

I certify that I have a working knowledge of the books and records of the establishment whose name appears above, and that to the best of my knowledge the figures presented above represent accurate sales totals for the period specified.

CPA Name (Printed) Name of CPA Firm

CPA Signature Business Address

City Phone #

Sworn under oath this day of , 20 . Notary Public Signature

II. I hereby affirm that I understand that the privilege of selling alcoholic beverages on Sundays from 12:30 p.m. until 2:55a.m. (Monday) requires a valid alcoholic beverage pouring license, valid Sunday Sales pouring license, and that at least 50% ofthe license establishment’s annual gross food and alcoholic beverage sales must be derived from the sale of prepared mealsand food. I hereby affirm that I understand that records of food sales and alcoholic beverage sales must be prepared andmaintained. Failure to prepare and maintain records of food sales and alcoholic beverage sales is cause for denial orrevocation of an alcoholic beverage pouring license, including a Sunday Sales pouring license. I further affirm that Iunderstand that the City of Stonecrest Business License division may audit our records to verify the same at its discretion.

Signature, Licensee/Owner

Sworn under oath this day of , 20 . Notary Public Signature

3120 Stonecrest Boulevard, Suite 100 Stonecrest, GA 30038

770.224.0200 www.stonecrestga.gov

BEER WHOLESALE EXCISE TAX RETURN BUSINESS NUMBER: MONTH OF:

BUSINESS NAME:

BUSINESS ADDRESS: CITY ISSUING LICENSE:

Each wholesaler selling malt beverages to dealers selling malt beverages within the City of Stonecrest, must collect a specific tax in the amount of $0.05 per 12 ounces, or proportionate part thereof as to graduate said amount of tax on smaller containers, and an excise tax on draft beer of $6.00 per container of not more than 15 1/2 gallon size, or proportionate part thereof within a bulk container commonly used for tap or draft beer sold by each wholesale dealer within the City of Stonecrest. This tax is due and payable to the City of Stonecrest monthly on or before the 15th day of the month following the month the tax was collected. Failure to pay by the due date will subject the licensee to the penalty and interest on the tax due. Remittance shall be accompanied by a statement under oath from a responsible person employed by the wholesaler showing the total sales of each type of malt beverage, by volume and price, disclosing for the preceding calendar month the exact quantities of malt beverages, by size and type of container, constituting a beginning and ending inventory for the month, sold to every person holding a retail license for the sale of malt beverages in the City of Stonecrest. Returns remitted by mail must be postmarked by the 15th of the month due. For example, the tax collected for the month of January is due and payable on or before February 15th.

COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4 COLUMN 5 COLUMN 6 Size of Container Beginning

Inventory Ending

Inventory Total Sold Tax Per

Container Tax Due:

7 oz. $0.0292 8 oz. $0.0333 12 oz. $0.0500 14 oz. $0.0583 16 oz. $0.0667 32 oz. $0.133 ½ Barrel (15 1/2 gal.)

$6.00

1 Barrel (31 gal.) $12.00 This return is subject to audit:

1. Multiply columns 4 and 5 to determine tax due amount payable (column 6) $2. Penalty (add 5% of line 1 for each month or fraction thereof, not to

exceed 25% if submitted after the 15th of the month) + $ _

3. Total Amount Due $ _

I DECLARE UNDER PENALTIES PRESCRIBED THAT THE INFORMATION PROVIDED IN THIS RETURN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Printed Name: Date:

Signed: Title:

Contact Phone: Fax:

Please return this form with remittance to:

City of Stonecrest 3120 Stonecrest Blvd Stonecrest, GA 30038

PLEASE MAKE A COPY FOR YOUR FILE AND RETURN THE ORIGINAL WITH YOUR PAYMENT Note: Incomplete forms will be returned to you to be fully completed

3120 Stonecrest Boulevard, Suite 100 Stonecrest, GA 30038

770.224.0200 www.stonecrestga.gov

ALCOHOL BEVERAGE WHOLESALE EXCISE TAX RETURN

BUSINESS NUMBER: MONTH OF:

BUSINESS NAME:

BUSINESS ADDRESS: CITY ISSUING LICENSE:

The excise taxes imposed by this division shall be collected by all wholesalers selling alcoholic beverages to persons holding retail licenses for sale to the same, in the City of Stonecrest. Said excise taxes shall be collected by the wholesalers at the time of the wholesale sale of such beverages. It shall be the duty of each wholesaler to remit the proceeds so collected, on or before the 15th day of each month, for the preceding calendar month. This remittance shall be accompanied by a statement under oath from a responsible person employed by the wholesaler showing the total sales of each type of wine and alcoholic beverage, by volume and price, disclosing for the preceding calendar month exact quantities of wine and alcoholic beverages, by size and type of container, constituting a beginning and ending inventory for the month, sold to every person holding a retail license for the sale of wine and alcoholic beverages in the City of Stonecrest. Failure to file such a statement, or to remit the tax collected on or before the 15th day of each month, shall be grounds for suspension or revocation of the license provided for by this chapter. Failure to pay by the due date will subject the licensee to the penalty and interest on the tax due. The excise tax levied on the sale of distilled spirits by the package, at the wholesale level, is hereby set at the rate of $0.22 per liter of distilled spirits, excluding fortified wines, and a proportionate tax at like rates on all fractional parts of a liter. The excise tax levied on the first sale or use of wine by the package is hereby set at $0.22 per liter, and a proportionate tax at like rates on all fractional parts of a liter.

This return is subject to audit:

1. Liters sold of distilled spirits x $0.22 per liter tax = $ 2. Penalty (add 5% of line 1 for each month or fraction thereof, not to

exceed 25% if submitted after the 15th of the month) + $

3. Total Amount Due $

I DECLARE UNDER PENALTIES PRESCRIBED THAT THE INFORMATION PROVIDED IN THIS RETURN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Printed Name: Date:

Signed: Title:

Contact Phone: Fax:

Please return this form with remittance to:

City of Stonecrest 3120 Stonecrest Blvd Stonecrest, GA 30038

PLEASE MAKE A COPY FOR YOUR FILE AND RETURN THE ORIGINAL WITH YOUR PAYMENT Note: Incomplete forms will be returned to you to be fully completed

3120 Stonecrest Boulevard Stonecrest, GA 30038

770-224-0200www.stonecrestga.gov

RETAIL EXCISE TAX RETURN ON LIQUOR BY THE DRINK Business Name: Business Address:

Account Number: Month/Year Reported:

A. Inventory—Liquor Reporting Only B. Excise Tax ReportingList your inventory purchases fromLicensed wholesaler for the month 1. Gross Liquor Sales by the Drink

2. Tax (-) 3% of line 2:1. ATL Wholesale Wine liters 3. Less 3% of line 2:(Timely Returns Only)2. Eagle Distributors liters 4. Credit or Debit3. Empire Distributors liters 5. Penalty (-)10% times Line 24. General Wholesale liters 25% fraud or intent to evade5. Georgia Crown Distributors liters 6. Interest- 1% per month or6. National Distributors liters portion thereof times line 27. Savannah Distributing liters 8. United distributors liters 9. Other: liters

Liters Purchased liters Total Amount Due

Total Cost of Liquor Purchased liters Total Amount Paid

This return and payment of the taxes collected during the month shown are due by the 20th day of the next month to avoid a late payment penalty and interest charges.

I DECLARE UNDER PENALTIES PRESCRIBED THAT THE INFORMATION PROVIDED IN THIS RETURN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Printed Name: Date:

Signed: Title:

Contact Phone: Fax:

Please return this form with remittance to:

City of Stonecrest 3120 Stonecrest Blvd Stonecrest, GA 30038

PLEASE MAKE A COPY FOR YOUR FILE AND RETURN THE ORIGINAL WITH YOUR PAYMENT

Note: Incomplete forms will be returned to you to be fully completed

BACKGROUND INVESTIGATION CONSENT FORM

To: Business License Division City of Stonecrest 3120 Stonecrest Blvd Stonecrest, GA 30038

With regards to my application for Alcoholic Beverage License, I hereby authorize the

Stonecrest Business & Alcohol License Office to receive any criminal history record

information pertaining to me, which may be in the files of any State or Local Criminal

Agency in Georgia.

Last Name First Name Middle Name

Street City State Zip

Sex Race Date of Birth

Signature Social Security Number Date*

*(Not valid after more than 90 days)

MUST BE COMPLETED BY REGISTER AGENT AND WHO MUST COMPLETE A PERSONNEL STATEMENT.

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